We present a case of a 74-year-old female with a past medical history of hypertension and metastatic pancreatic cancer presenting with abdominal pain, nausea, vomiting and diarrhea. The patient completed her second cycle of FOLFIRINOX one week prior to presentation and had been having diarrhea ever since. Of note, she had presented to a different facility three weeks prior after her first round of FOLFIRINOX. She was admitted for possible colitis at that time, though her stool cultures returned negative. However, on the day of presentation, she abruptly began to experience sharp, stabbing pain in her right side associated with projectile vomiting and nausea. Upon presentation to a satellite emergency room, she was afebrile with a heart rate of 86, blood pressure of 124/88, saturating appropriately on room air. Her physical exam was pertinent for diffuse abdominal tenderness particularly tender to palpation in the epigastrium and right lower quadrant without guarding or rebound.

The patient’s initial laboratory values to include a Complete Blood Count (CBC) with differential revealed a white blood cell (WBC) count of 2.4 with an ANC of 500. A contrast CT scan of the abdomen and pelvis with intravenous contrast demonstrated mild colonic thickening in the ascending and transverse segments (Figure 1). Blood cultures, stool PCR, and Clostridium difficile stool cultures were ordered and she was subsequently initiated on broad-spectrum antibiotics with piperacillin-tazobactam. The following day, the patient became intermittently febile and her oncologist was notified of her admission. The primary team was advised to place the patient on Filgrastim for expected post-chemotherapy pancytopenia. The patient was monitored closely for signs of peritonitis and she continued to improve clinically despite ongoing intractable nausea. Blood cultures remained negative and antibiotics were discontinued after 5 days.